Having a Baby after Cancer

Side effects of cancer treatments can include early menopause, but there are new medical advances to help female cancer patients preserve their ability to have a baby. Why aren't doctors talking about this with their patients before treating them?

Having a baby wasn't supposed to be so complicated. But that's what Alice Crisci's life had suddenly become, beginning on that otherwise unremarkable Sunday afternoon in early 2008 when she scratched an itch high above her left breast and felt a marble-like lump. In the weeks and months that followed a diagnosis of breast cancer, the 31-year-old Los Angeles-based entrepreneur would undergo a double mastectomy, breast reconstruction, and six cycles of a potent chemo cocktail guaranteed to kill off any remaining cancer cells—along with her chances of having a baby. Everyone kept telling her she'd be fine. But as Alice saw it, nothing was fine about discovering that the chemo needed to save your life would very likely throw you into early menopause...before you'd had children.

Two days after her diagnosis, she sat on an examining table, sobbing to a friend who had come along for moral support. The one-two punch of cancer and infertility was suddenly hitting her. The friend, who'd been on a Googling tear from the moment Alice told her about the lump, asked if she'd thought about freezing her eggs. She could have them harvested before chemotherapy could damage or destroy them, the friend pointed out, and five years from now, when (not if) Alice was cancer-free, she would have a chance to get pregnant at start a family.

Alice ran the idea past her breast surgeon, who was all for it but suggested holding off until after she had her double mastectomy. She would have four to six weeks to recuperate before beginning chemo, and she could undergo egg retrieval then. The focus right now should be on surviving cancer. "I don't want you to get overwhelmed," the breast surgeon told Alice.

"I'm already overwhelmed," she replied. She consulted a fertility specialist and was told that waiting until after surgery to harvest her eggs would be risky. Anesthesia, the specialist explained, can cause a woman to skip her period. If that happened, Alice wouldn't have a chance to get her eggs harvested before her chemo treatment began. Another thing: At the time, egg freezing had an estimated pregnancy success rate of only 2 to 3 percent, so the fertility specialist recommended embryo freezing as well, which has a much higher success rate. Given the narrow time frame, Alice would have to start hormone injections (to stimulate her ovaries) the next day.

She had fewer than 24 hours to figure out how she'd cover the out-of-pocket costs of harvesting her eggs and freezing them. Plus, since her boyfriend chose this particular moment to tell her he didn't see a future for the two of them, she had to pick a sperm donor so that embryos could be created with half the eggs. She ended up with 11 frozen eggs, 14 frozen embryos, and an American Express bill for $20,000. She also had—whether she realized it at that moment or not—a powerful incentive to beat the cancer.

The Misinformation Maze Not so long ago, the odds of getting pregnant and having a baby after cancer were about as grim as surviving cancer itself. "Twenty years ago, cancer was a killer," says Marybeth Gerrity, Ph.D., executive director of the Oncofertility Consortium, a national program based at Northwestern University's Feinberg School of Medicine that is working on new ways to protect cancer patients' reproductive health. "Because treatment has become so effective—drug companies are designing new drugs, radiation is more effective—a lot of cancers are no longer a death sentence. Now we're looking at survivor and quality-of-life issues. And for young people, that often means starting a family."

And yet, research suggests that most of the oncologists treating women in their baby-bearing years—and of all the cancers diagnosed in women each year, 12 percent occur in women under age 45—fail to discuss fertility preservation with their patients. Men are at risk of fertility problems too, but the solution for them has always been within easier reach (so to speak). Since sperm is available every day of the month, a man who's diagnosed with cancer simply needs to be told where to bank his sperm (although studies suggest only about half are actually told they should consider doing so). But fertility preservation for women is more complicated.

For starters, we're born with all the eggs we'll ever have, and when we run out, that's it: Menopause begins. Chemo can throw a woman into early menopause (a.k.a. premature ovarian failure) by affecting her ovaries' ability to make the hormones necessary in order for her to get her period. Even if a woman gets her period again, she'll often have "diminished ovarian reserve," meaning her eggs were damaged or destroyed by treatment. Her ovaries are still functioning, but she may have difficulty conceiving, with or without fertility treatment— especially if she's over age 35.

"A lot of physicians who'd recommend sperm banking to a man don't realize that there are options for women."

The most common solution—fertilizing eggs with sperm through in vitro fertilization (IVF) and then freezing the embryos—is a relatively straightforward procedure. But egg retrieval can't be done just any day of the month, and fertility drugs must be used to ripen a large number of eggs. The process takes two to three weeks, depending on where the woman is in her cycle. The same is true if the woman wants to freeze her eggs without having them fertilized.

And that's the rub: Even though survival rates are up, oncologists still view the Big C as plenty big. Their priority, understandably, is to save lives. As a result, they're reluctant to postpone a patient's cancer treatment for any reason, even though studies show there's little risk in delaying chemotherapy or radiation for most of the cancers that are common among young women: breast and colorectal cancers, and lymphoma.

In 2006, the American Society of Clinical Oncology (ASCO) issued guidelines saying that any oncologist with reproductive-age patients should discuss how treatment may affect their fertility. And yet according to a study last year from the Moffitt Cancer Center and Research Institute, only 46 percent of oncologists report referring patients for fertility preservation.

"Some of the chemotherapy drugs are so new that physicians don't yet know their impact on fertility," explains Gerrity. "Other doctors have a paternalistic approach—they feel the patient has enough to worry about. They don't want to burden her. A lot of physicians who would recommend sperm banking to a man don't realize that there are options for women."

Shortly before her surgery, Alice found out that an old friend from high school, Patty Bernardo, then 34 and a senior consultant for an I.T. firm in Fairfax, Virginia, had been diagnosed with breast cancer too. Their cases were similar. Like Alice, Patty's course of treatment included a bilateral mastectomy, breast reconstruction, and chemotherapy, followed by a year on the antiestrogen drug Tamoxifen. Unlike Alice, Patty was married, though she and her husband of 11 years hadn't yet started a family. When her team of doctors asked her if she had kids, she answered each of them the same way: "Not yet. Maybe someday." Her breast surgeon said he hated that she wouldn't be able to breast-feed her future children. Her oncologist was hopeful: Chemo could throw her into premature menopause, he said, but the chances of getting her period back should be high.

Patty says neither doctor talked to her about fertility preservation. Just the opposite, in fact. By the time her original cancer treatment was behind her, her medical team concurred, she'd be 37—still young enough to have a baby. It wasn't until Alice mentioned her frozen eggs and embryos that Patty even knew of the possibilities. But by then, she had completed chemo. It was too late.

Like half of all female cancer patients younger than 40 who undergo chemo, Patty's period returned after she completed treatment. But that's no guarantee of fertility. "My husband and I had been in no hurry to have a baby, but at least that was our choice," she says. "When someone takes it from you, that's a shot in the gut." Now they're considering their options, including adoption.

Brave New Medical World Patty's situation is hardly unique: According to ASCO, recent surveys of cancer survivors of reproductive age show that at least half have no memory of a discussion of fertility with their doctors. And the few studies of oncologists confirm what patients recall.

"The majority of cancer patients are over 60, so the average oncologist isn't accustomed to taking care of young patients," says Leonard Sender, M.D., director of the Young Adult Cancer Program at the University of California at Irvine and the Children's Hospital of Orange County. "As a result, the consequences of the cure are often missed." And until about 15 years ago, when embryo freezing became an option, there was little that could be done in the way of fertility preservation anyway.

In 2007, the National Institutes of Health began financing the Oncofertility Consortium, and researchers there are studying methods to better preserve patients' fertility that may be lost due to treatment. They're testing cancer drugs to determine their effects on a woman's ovaries and researching ways to shield eggs and sperm from toxic cancer treatments.

"Every young patient should be advised of what options might be right for them," says Teresa Woodruff, Ph.D., chief of fertility preservation and a professor of obstetrics and gynecology at the Feinberg School. For women who can delay cancer treatment for up to a month, egg and embryo freezing may be the most effective ways to preserve fertility. If a woman can't put off treatment, ovarian tissue freezing and transplantation is an option: An ovary is removed, and the outer layer, where all the eggs are located, is stripped off, frozen, and then transplanted back into her body when she's ready to get pregnant. Fewer than a dozen babies have been born in the United States using this procedure, all of them at the Infertility Center of St. Louis at St. Luke's Hospital, but that's mostly because transplantation is still relatively new: It wasn't until 2004 that doctors were able to successfully transplant the tissue back into a woman's body, though they've been able to surgically remove and freeze ovarian tissue since the late 1990s.

One of the goals of the new oncofertility movement is to eliminate last-ditch solutions by bringing fertility specialists into the loop at the outset. "The doctor on the front line is the oncologist," notes Sender. At a small but growing number of cancer centers across the country, new software makes it impossible for physicians treating a newly diagnosed patient to close out her electronic medical record without answering two questions: "Did you talk to this patient about fertility preservation?" and "Does the patient want a fertility preservation consult?" The answer to the first question must be yes, and if the answer to the second one is also yes, the Oncofertility Consortium automatically receives an e-mail and the patient is contacted within 24 hours.

Life Goes On Even if a patient chooses not to undergo fertility preservation, simply having the conversation reframes the larger picture. "Talking about a deadly disease and the hope of future fertility in the same moment changes the dialogue in an extraordinary way," says Woodruff.

It did for Alice Crisci. She not only took steps to preserve her fertility options but also launched Fertile Action, a foundation that helps young women with breast cancer. Ultimately, if she falls in love with a great man, she'd like to try to have kids with him. But she also wants to have babies from her embryos, which in her mind were much more than a backup plan. Says Alice: "They gave me hope during a very dark time."

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